Clinical Audit, Service Evaluation and Quality Improvement Policy V7 1 Clinical Audit, Service Evaluation and Quality Improvement Policy Solent NHS Trust policies can only be considered to be valid and up-to-date if viewed on the intranet. Please visit the intranet for the latest version. Purpose of Agreement This policy sets out a framework for the conduct of clinical audit, service evaluation and Quality Improvement work within Solent NHS Trust Document Type Policy Reference Number Solent NHST/Policy/CLS06 Version Version 7 Name of Approving Committees/Groups Learning Effectiveness and Improvement Group Policy Steering Group, Trust Management Team Meeting Operational Date September 2019 Document Review Date September 2022 Document Sponsor (Job Title) Associate Director of Research and Clinical Effectiveness Document Manager (Job Title) Quality Improvement and Clinical Effectiveness Manager Document developed in consultation with Learning Effectiveness and Improvement Group Clinical Audit and Evaluation Team Quality Improvement Team Intranet Location Business Zone > Policies, SOPs and Clinical Guidelines Website Location Publication Scheme Keywords (for website/intranet uploading) Clinical, Audit, Policy, Clinical Audit Policy, Service Evaluation, Quality Improvement, CLS06
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Clinical Audit, Service Evaluation and Quality Improvement Policy V7 1
Clinical Audit, Service Evaluation and Quality Improvement Policy
Solent NHS Trust policies can only be considered to be valid and up-to-date if viewed on the intranet. Please visit the intranet for the latest version.
Purpose of Agreement
This policy sets out a framework for the conduct of clinical audit, service evaluation and Quality Improvement work within Solent NHS Trust
Document Type Policy
Reference Number Solent NHST/Policy/CLS06
Version Version 7
Name of Approving Committees/Groups
Learning Effectiveness and Improvement Group
Policy Steering Group, Trust Management Team Meeting
Operational Date September 2019
Document Review Date September 2022
Document Sponsor (Job Title) Associate Director of Research and Clinical Effectiveness
Document Manager (Job Title) Quality Improvement and Clinical Effectiveness Manager
Document developed in consultation with
Learning Effectiveness and Improvement Group
Clinical Audit and Evaluation Team
Quality Improvement Team
Intranet Location Business Zone > Policies, SOPs and Clinical Guidelines
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 2
Amendments Summary:
Amend No
Issued Page Subject Action Date
July 2019 5-14 Version 7 of this policy was a major re-write to incorporate Quality Improvement projects. It also incorporated new practice from the integrated Academy of Research and Improvement and use of SolNet.
July 2019
July 2019 5 1.1 Table introduced to explain the differences between audit, research, service evaluation and QI
July 2019
July 2019 7 3.0 Diagram introduced to illustrate the process for these projects.
July 2019
July 2019 8 3.2 Section added for trust values, patient and public engagement.
July 2019
July 2019 9 3.4 Improvement planning event added.
July 2019
July 2019 12 3.14 Section added on sharing learning with examples of new practice.
July 2019
July 2019 15 Appendix 1 – responsibilities of board and assurance committee updated to reflect current terms of reference.
July 2019
Review Log:
Version Number
Review Date Lead Name Ratification Process Notes
6 March 2016 Tracey Deadman
Solent NHS Trust Policies Group Policy rewritten and shortened
7 April 2019 Colin Barnes
Solent NHS Trust Policies Group Policy revised to reflect current practice, linked to intranet resources and an overview of Quality Improvement processes added
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 3
Summary of Policy
The purpose of this policy is to ensure that Solent NHS Trust meets its statutory and mandatory
requirements for clinical audit and uses quality improvement tools to demonstrate effectiveness,
drive improvement and share learning. It sets out a framework for staff carrying out clinical audit,
service evaluation and quality improvement projects in Solent NHS Trust. These processes should
provide evidence of effectiveness for assurance, plans for and evidence of improvement as well as
learning that can be shared across the organisation.
This policy is intended for use by all Solent staff participating in and responsible for using these
processes. This policy also applies to employees of partner organisations conducting clinical audit,
evaluation or quality improvement with staff, patients or data from this trust.
This policy includes definitions of each of these methods and details the processes required to
undertake them. Roles and responsibilities for conducting these processes are also defined.
Clinical Audit
Clinical audit measures the quality of care and services against agreed standards, making
improvements where necessary.
Service Evaluation
Service evaluations consider if existing or newly implemented services are effective. This process
explores what is happening in a service as well as outcomes and experience for patients.
Quality Improvement (QI)
QI is a systematic process using QI theory and methods to continually make small changes that lead
to measurable improvements for targeted services or patient populations.
Statutory and Mandatory requirements
Healthcare providers must participate in relevant national clinical audits within the National Clinical
Audit and Patient Outcomes Programme (NCAPOP). Healthcare providers must also review
implement relevant recommendations of any national clinical audit (NHS Standard Contract).
Healthcare providers must implement a programme of clinical audit (NHS Standard Contract) to
regularly assess and monitor the quality of the services provided (CQC Essential Standards). They
must use the findings from clinical and other audits to ensure that action is taken to protect people
who use services from risks associated with unsafe care, treatment and support (CQC Essential
Standards).
Healthcare providers must produce an annual Quality Account, which must include information on
participation in national and local audits, and the actions that have been taken to improve services,
as a result of audits (NHS Quality Account Regulations, 2017).
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 4
Table of Contents
CONTENTS
1 INTRODUCTION AND PURPOSE
1.1 Introduction 5
1.2 Purpose of this policy 6
1.3 Statutory and mandatory requirements for clinical audit 6
2 SCOPE & DEFINITIONS 6
3 PROCESS REQUIREMENTS 7
3.1 Academy of Research and Improvement 8
3.2 Trust values, patients and the public 8
3.3 Involving students, researchers and other partners 9
3.4 Improvement Planning event 9
3.5 The QI plan/tracker 9
3.6 The CA and SE plan 10
3.7 Changes to the CA and SE Plan 10
3.8 CA and SE Progress reporting 10
3.9 Participation in National and Contractual audits 10
3.10 Corporate Team Audits 11
3.11 Conducting local CA, SE and QI projects 11
3.12 Registration Process 11
3.13 Action Plans 12
3.14 Sharing Learning and dissemination 12
4 ROLES AND RESPONSIBILITES 13
5 TRAINING 13
6 EQUALITY IMPACT ASSESSMENT AND MENTAL CAPACITY 13
7 SUCCESS CRITERIA / MONITORING EFFECTIVENESS 13
8 REVIEW 14
9 GLOSSARY 14
APPENDICES
1 Responsibilities of Solent NHS Trust Staff and Committees 15
2 Information Governance: collection, storage and retention of data and confidentiality
18
3 Audit Cycle and The Model for Improvement 19
4 Equality Impact Assessment 20
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 5
Clinical Audit, Service Evaluation and Quality Improvement Policy
1. INTRODUCTION & PURPOSE 1.1 Introduction
Table 1 below describes the differences between research, clinical audit, service evaluation and
quality improvement.
Research Clinical Audit (CA) Service Evaluation (SE)
Quality Improvement (QI)
Designed to derive
generalisable new
knowledge
Designed and conducted
to produce information
to inform delivery of best
care
Designed and conducted
to define or judge
current care
Uses a range of tools to
make on-going
improvements to services,
usually via small scale
tests of change
Designed to test a
specific hypothesis
Asks “does this service
reach a predetermined
standard”
Asks “what standard
does this service achieve”
Asks “how could this
service improve” and
measures the
effectiveness of
improvements
Identifies concerns,
effectiveness,
improvement and
learning
Identifies concerns,
effectiveness,
improvement and
learning
Identifies concerns,
effectiveness,
improvement and
learning.
Identifies concerns,
effectiveness,
improvement and
learning.
Addresses clearly defined
questions, aims and
objectives
Measures against a
standard
Measures without
reference to a standard
Uses measurement to
understand services and
test ideas for
improvement
Study may involve
allocating patient to
intervention groups
No allocation to
intervention
No allocation to
intervention.
No allocation to
intervention
Normally requires formal
ethics committee review
Does not require formal
ethics review
Does not require formal
ethics review
Does not require formal
ethics review
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 6
1.2 Purpose of this policy
The purpose of this policy is to ensure that Solent NHS Trust meets its statutory and mandatory
requirements in relation to clinical audit. It sets out a framework for staff undertaking clinical audit,
service evaluation and quality improvement projects in Solent NHS Trust. These processes should
provide evidence of effectiveness for assurance, plans for and evidence of improvement as well as
learning that can be shared across the organisation.
1.3 Statutory and Mandatory requirements for clinical audit.
The NHS Standard contract states that healthcare providers must participate in relevant national
clinical audits within the National Clinical Audit and Patient Outcomes Programme (NCAPOP).
Healthcare providers must also review and where relevant implement all relevant recommendations
of any national clinical audit.
The Care Quality Commission (CQC) requires healthcare providers to regularly assess and monitor
the quality of the services provided. They must use the findings from clinical and other audits,
including those undertaken at a national level, and national service reviews to ensure that action is
taken to protect people who use services from risks associated with unsafe care, treatment and
support. They must also ensure healthcare professionals are enabled to participate in clinical audit in
order to satisfy the demands of the relevant professional bodies (for example, for revalidation).
The National Health Service (Quality Account) Regulations 2017 requires healthcare providers to
produce an annual Quality Account, which must include information on participation in national and
local audits, and the actions that have been taken to improve services, as a result of the audit.
A list of the key statutory and mandatory requirements for clinical audit is available on the
2. SCOPE & DEFINITIONS This policy applies to locum, permanent, and fixed term contract employees (including apprentices)
who hold a contract of employment or engagement with the Trust, and secondees (including
students), volunteers (including Associate Hospital Managers), bank staff, Non-Executive Directors
and those undertaking research working within Solent NHS Trust, in line with Solent NHS Trust’s
Equality, Diversity and Human Rights Policy. It also applies to external contractors, agency workers,
and other workers who are assigned to Solent NHS Trust.
This Policy also applies when clinical audit or service evaluation is undertaken jointly across
organisational boundaries (partnership working). The Leads of these projects must follow the
process described in this policy and any relevant policy in the partner organisation.
“Solent NHS Trust is committed to the principles of Equality and Diversity and will strive to eliminate unlawful discrimination in all its forms. We will strive towards demonstrating fairness and Equal Opportunities for users of services, carers, the wider community and our staff.
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 7
3. PROCESS/REQUIREMENTS The diagram below illustrates the steps involved in carrying out CA, SE or QI projects referring to relevant sections within this policy.
Identifying
•Quality themes are identified by corporate and clinical teams. Projects for the year ahead are drafted at the annual improvement planning event (3.4) or through liason with services during the year (3.12) and agreed by service line governance. Project types are determined (1.1).
Registration
•Annual "improvement planning event" projects are added to the plan (3.4)
•The Improvement team are advised of additional projects which may require approval (3.12)
Plan
•Plans for CA, SE and QI projects are held on SolNet maintained by the Improvement team (3.1)
•Plans are reviewed by service line audit and QI groups/networks
Training
•Training is provided for CA and SE. QI projects are associated with QI foundation, practitioner or leader programmes or QI trained staff (5)
Support
•Support is provided by the Improvement team (3.1)
Engagement
•Wherever possible patients and the public are engaged and involved in projects (3.2)
Actions
•Action plans for improvement are made for CA and SE projects (3.13)
Reporting and sharing
•Reports are produced where required by service lines for CA and SE. Single page summaries and other media are produced for projects to highlight concerns, effectiveness, engagement, improvement and learning (3.14)
Themes and Impact
•Themes for further projects including repeat audits and evalautions are identified e.g. for improvement planning the following year (3.4). The impact of shared learning is measured.
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3.1 The Academy of Research and Improvement
Solent NHS trust has an integrated research and improvement team within the Academy of Research
and Improvement. Information on all the activities of the Academy are detailed on SolNet
All audit, evaluation and QI plans should reflect the Trust Values in their planning, conduct and plans
for improvement. https://www.solent.nhs.uk/our-story/our-values/
Patients and people who access our services provide a unique perspective and understanding which can be different to that experienced by staff. NHS staff can become familiar/take for granted the way services are run. Our expected care outcomes may also be different.
Involving patient and the public in clinical audits, service evaluations and quality improvement enables us to take their perspective into account and direct improvements towards what matters to them. Where patients and communities have been involved in improvement work this has resulted in enriched and effective outcomes.
Involvement can be as simple as asking people to complete a patient or carer survey in a service evaluation. Engagement can be as broad as asking patients and the public what areas we should be focusing on and how to go about that, what processes to use and what questions to ask. Once projects are completed, patients and the public can help us interpret our findings e.g. where service evaluations use clinical outcomes, patients can help determine what a meaningful outcome is.
All CA, SE and QI projects leads should ask;
Is this project important to patients and the public?
Can we engage them early on?
Where can we involve patients in this project?
What standards or areas for improvement are important to them?
Are our expected outcomes important to patients?
How can we share and review our findings with our patients?
The Academy of Research and Improvement seeks continuous and meaningful engagement for improvement with patients and the public to shape our services and to improve healthcare in the community. The Academy team can support services in how to engage, involve, and work with their patients, carers and community groups. A variety of patient engagement tools and methods can be used to guide services to engage in a meaningful and purposeful way.
The Academy of Research and Improvement work with patients through the Side-by-Side network.
Side-by-Side works to share as well as to promote being involved in research and improvement.
All CA and SE reports should contain a detailed action plan which has been agreed by the service
prior to submission of the report. Where summaries are submitted a separate detailed action plan
should be produced. The project leads and the service line audit and QI group are responsible for
ensuring actions are carried out.
Actions can include steps to be taken to share results and learning but should primarily be actions
for improvement. Where actions for improvement are required, re-audit or re-evaluation should be
planned to demonstrate the effect of the actions.
Actions should be specific individual actions with stated end dates. The action should be
measureable and assigned to an individual. The CA and SE report template includes an action
planner designed to meet these criteria.
3.14 Shared learning and dissemination
Learning from projects should be shared across the organisation. Wherever possible, the impact of this shared learning should also be measured. Learning can include;
Changes in process that have led to improvement that could be adopted elsewhere
Information about what is happening in a service that was previously unclear
Information about patient experience and patient outcomes
Information about patient and staff current and future preferences
Detailed information on Solent NHS Trust CA, SE QI activity is maintained on the trust intranet pages
and Academy website. This includes examples of full reports and project summaries.
Templates for CA and SE project reports are available on the intranet and should be used for more
detailed projects and where the dissemination and reporting process in service lines require a more
detailed write-up and action plan. Adequate data from projects should be shared with the CE and QI
team and stored by the project lead to enable future repeat audits/evaluation/measurement. All CA,
SE and QI projects should also have a single page summary produced. A template and examples for
summaries from CA, SE and QI projects is available on SolNet.
Projects groups should share their results, planned actions, evidence of improvement and learning;
At local governance, QI and audit meetings
Project groups are also encouraged to;
Present a summary at the trust learning, effectiveness and improvement group
Produce posters, video and info-graphics
Communicate findings via social media such as Twitter, Facebook and trust communications
Present at celebration events and the research and improvement annual conference
Present at national conferences and submit for peer reviewed publication
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 13
4. ROLES & RESPONSIBILITIES Roles and responsibilities are detailed in Appendix 1. 5. TRAINING The Improvement team will make suitable training available, at venues throughout the Trust, to
include, but not limited to, the following:
junior doctors’ induction sessions
preceptorship programme sessions
patients and / or members of the public (participating in QI, audit or evaluation)
all other groups and individuals via -
o bespoke sessions as requested
o pre-arranged workshops on CA, SE and QI
o related workshops e.g. on library use, outcome measures, social media provided by the
Academy of Research and Improvement
Additional educational resources on clinical audit processes and quality improvement are available
on the intranet pages for Clinical Audit and QI. Additional resources are available through the HQIP
website
6. EQUALITY IMPACT ASSESSMENT AND MENTAL CAPACITY Equality Impact Assessment is attached at Appendix 4.
7. SUCCESS CRITERIA / MONITORING EFFECTIVENESS The implementation of this Policy will be monitored at the end of each financial year when the
Improvement Annual Report and Quality Account are written.
The Quality Account will show:
Solent’s participation in mandatory national audits
Implementation of the recommendations of national audits
Number of local audits reviewed and actions taken as a result of those audits
Brief examples of concern, effectiveness, learning and improvement from local and national
clinical audit and service evaluation
Examples of QI projects and the number of people attending training
The Annual Report will show:
Training delivered
CA, SE and QI Plan completion rate
Case study examples of concerns, effectiveness, improvement and learning as a result of
clinical audits, evaluations and quality improvement projects.
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 14
8. REVIEW This document may be reviewed at any time at the request of either at staff side or management,
but will automatically be reviewed 3 years from initial approval and thereafter on a triennial basis
unless organisational changes, legislation, guidance or non-compliance prompt an earlier review.’
9. GLOSSARY
IMPROVEMENT Team Clinical Audit and (Service) Evaluation Team
NCAPOP National Clinical Audit & Patient Outcome Programme
QI Quality Improvement
SE Service Evaluation
HQIP Healthcare Quality Improvement Partnership
PIS Participant Information Sheet
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 15
APPENDIX 1
Responsibilities of Solent NHS Trust Staff and Committees
All staff
All staff employed by the Trust have a responsibility for the quality of the service which they provide, and all healthcare professionals are individually accountable for ensuring they audit their own practice in accordance with their professional codes of conduct and in line with this Policy.
Where actions for improvement are agreed by service line governance, nominated individuals are responsible for delivering those actions within agreed time frames.
Staff conducting CA, SE and QI projects are responsible for:
Ensuring that they have adequate training
Ensuring projects are approved by service lines and registered with the CE or QI team
Considering the potential for patient engagement
Following information governance policies and guidance
Recording and reporting sufficient information in reports and summaries alongside detailed
plans for improvement where required
Sharing results and learning as widely as possible
CE and QI teams have responsibility for:
Coordinating the annual improvement planning event
Identifying appropriate national audits
operational oversight of the Clinical Audit, Evaluation and Quality Improvement (QI) Plan/Tracker
offering support to those involved in undertaking clinical audit, including provision of audit tools that provide some automatic data analysis capability
promoting and providing in-house clinical audit training
providing training and facilitation for people learning about and running QI projects
maintaining a database of audit and service evaluation activity
producing monthly updates to services on projects completed/due
co-ordinating approval of service evaluations
preparing annual reports
ensuring that the staff have access to further relevant training in order to maintain and develop their knowledge and skills
attending service line Audit and QI meetings as per the requirements of each service line
Nominated Persons with service line responsibility for Clinical Audit (NPs)
(E.g. heads of quality and professions/governance leads/clinical audit leads) have responsibility for:
working with the service line manager to ensure there is a clinical audit, Service evaluation or QI Plan for their services
working with the Improvement Team to ensure their service participates in all relevant audits, national confidential enquiries and service reviews
ensuring their QI Plan meets all clinical, statutory, regulatory, commissioning and other Trust requirements
supporting the implementation of changes identified by audit
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 16
Quality Improvement and Clinical Effectiveness Manager has responsibility for:
day to day management of clinical audit, service evaluation and QI activity across Solent NHS Trust
overseeing the participation of team members in professional training and development activities, including those organised by the Q network, HQIP and the South Central Clinical Audit Network
co-ordinating the development, and implementation of Solent NHS Trust’s Clinical Audit and Service Evaluation Strategy and the Trust’s QI Plan
supporting the continuing development and promotion of a proactive clinical effectiveness, audit, governance, quality improvement and evidence based practice culture
implementation and monitoring of the clinical effectiveness components of the Care Quality Commission (CQC) standards
Associate Director of Research and Clinical Effectiveness:
Has responsibility for ethical oversight of clinical audits and service evaluation projects, and for
operational delivery of the CA, SE and QI Plans.
Chief Medical Officer:
Has responsibility for:
ensuring that the annual CA, SE and QI plans are allied to the Board’s strategic interests and concerns;
ensuring that the annual plans are used appropriately to support the Board Assurance Framework;
ensuring this Policy is implemented across all clinical areas;
ensuring that any serious concerns regarding the Trust’s Policy and practice in clinical audit, service evaluation or QI, or regarding the results and outcomes of clinical audits, are brought to the attention of the Board;
ensuring participation in national audit
Chief Executive:
Has responsibility for the statutory duty of quality and overall responsibility for this Policy, aspects of which may be delegated to other groups or individuals.
COMMITTEES
Trust Board is responsible for:
the strategic direction of the organisation setting priorities seeking assurance that actions have resulted in improvements ensuring that the planned participation in national and local audits is effectively prioritised
to meet the organisation’s objectives and statutory requirements
Service line QI/Clinical Audit groups are responsible for providing oversight and guidance for clinical audit and service evaluation activity within their service line. Oversight includes;
informing and submitting annual plans for governance approval tracking projects on the plan to ensure timely completion promoting audit and evaluation activity in the service line
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 17
The Learning Effectiveness and Improvement Group is responsible for providing oversight and guidance for all clinical audit, service evaluation and QI activity within all clinical services in Solent NHS Trust. The group is also responsible for promoting trust wide learning e.g. from audit/QI actions that have led to improvement.
Audit and Risk Committee is responsible for:
seeking assurance that the Trusts’ activities are efficient, effective and represent value for money
reviewing the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objectives
the Trust’s Quality Accounts
Assurance Committee is responsible for:
seeking assurance and scrutinising all matters relating to quality and regulatory compliance – including seeking assurance of progress against action plans across the organisation, including those generated by CQC visits;
enabling the Board to obtain assurance that high standards of care are provided by the Trust, and in particular, that adequate and appropriate governance structures, processes and controls are in place throughout the Trust to:
promote quality, safety and excellence in patient care ensure the effective and efficient use of resources ensure there is compliance with all statutory requirements.
reviewing the quality account and seeking assurance on progress against quality account priorities
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 18
APPENDIX 2
Information Governance: collection, storage and retention of data and confidentiality
All clinical audits / service evaluations must adhere to NHS Information Governance (I G) policies and
standards. Further information is available on the Trust’s I G intranet pages.
Project leads should pay special attention to the Data Protection Act (2018) including the GDPR
(General Data Protection Regulations).
Collection, storage and retention of data
Collected data should be:
adequate, relevant and not excessive
stored securely, in line with NHS Records Management standards
processed for limited purposes
not kept for longer than is necessary (in Solent NHS Trust this means that raw data gathered
during clinical audit should be destroyed once the audit report and action plan have been agreed
by the relevant service line governance group)
Data confidentiality
The NHS Confidentiality Code of Practice (2003) states that “patients understand that some
information about them must be shared in order to provide them with care and treatment, and
clinical audit, conducted locally within organisations is also essential if the quality of care is to be
sustained and improved. Efforts must be made to provide information, check understanding, and
reconcile concerns and honour objections. Where this is done there is no need to seek explicit
patient consent each time information is shared”.
At the time of writing, a national data opt-out process was in development by NHS digital. Project
leads are responsible for checking any patient records used for audit and evaluation to ensure that
patients have not specifically opted out of participation/use of data for these purposes.
Trusts should inform patients that their personal health information will be used for clinical audit
and quality improvement purposes through references to this in patient information material (and
briefly describe the clinical audit process and its contribution to the quality and safety of patient
care).
Anyone who is not an employee of Solent NHS Trust but is involved in a QI project that requires
access to patient information will require a trust honorary contract and need to adhere to trust
policies.
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 19
Appendix 3
Clinical Audit, Service Evaluation and Quality Improvement Policy V7 20
